South Africa (SA) is a hard drinking country. It is reckoned that we consume in excess of 5 billion litres of alcohol annually; this figure is likely to be higher still if sorghum beer is included, and equates to 9 - 10 litres of pure alcohol per person. According to a World Health Organization (WHO) report released in 2011, this is among the highest per capita consumption rates in the world, and it is continuing to rise.

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More alarming still is that the WHO awards South Africa a score of 4 (drinking 5 or more beers or glasses of wine at one sitting for men, and more than 3 drinks for women) out of 5 on a least risky to most risky patterns-of-drinking scale - the higher the score, the greater the alcohol-attributable burden of disease for the country.2

This readership will not need reminding of the associated disease burden. But it is worth contemplating the financial and social cost. The cost to the fiscus, 'that relates to absenteeism, poor productivity, high job turnover, interpersonal conflict and injuries and damage to property, is reckoned to be around R9 billion per year, equivalent to 1% of GDP'.3 A high social cost accrues from the behaviour that attends drunkenness: crime (murder and assault, rape, robbery), interpersonal - including domestic - violence, sexual offences against children, reckless driving (or walking) accounting for road traffic deaths and injuries involving passengers and pedestrians, unsafe sex and sexual promiscuity with transmission of sexually transmitted diseases (STDs), fetal alcohol syndrome and child neglect, and school truancy.

Alcoholism among youth is a particular concern,4 given that at least half of SAs population are categorised as young people, under 35.1

Surveys have shown that alcohol use among our youth is common4,5 and increases with age for both males and females. There is also a tendency to more harmful binge drinking. Reasons for use and misuse of alcohol include peer pressure and a desire to fit in, poor home environs and boredom, ignorance of alcohol's harms, and the relative cheapness of alcohol products and their ease of access. High youth unemployment rates must be an exacerbating factor. And in SA, alcohol is easily purchased from bottle stores, supermarkets, bars and shebeens and other unlicensed liquor outlets, which outnumber licensed ones, particularly in disadvantaged communities.4

The problem is not peculiar to SA. Many countries, of which the UK is but one, lament their own experience of harmful drinking by youngsters. A recent UK report extensively reviews the vulnerability of youth to alcohol's harms.6 Adverse outcomes in children and young people range from the hard to the soft.

Easily appreciated hard effects are acute alcohol poisoning and liver disease, UK hospitals regularly describing patients in their early 20s with alcohol-related hepatitis, and women with cirrhosis by the time they are 30.6,7 Then there are injury, often as a result of assault, and unprotected sex leading to high levels of teenage pregnancy and risk of contracting STD, including, in SA, HIV. Softer outcomes include the physical (appetite changes, weight loss, eczema, headaches) and the behavioural (sleep disturbance, poor school and college performance, failure to form and maintain friendships, tendency to depression and/or aggressive behaviour, and greater likelihood of experimenting with cannabis and other illegal substances).6 Less well appreciated, perhaps, is that the adolescent brain, which is still growing, is especially vulnerable to alcohol's toxic effects, with risk of cognitive deficits, poor executive functioning and poor long-term memory.8

What is to be done? There have been a number of educational initiatives and attempts on the part of both governmental and nongovernmental organisations to mitigate the effects of boredom and social deprivation in our communities, yet the problem of alcohol misuse persists.

Recently the Minister of Health has suggested a ban on alcohol advertising and sponsorship; he wishes also to raise the age of legal alcohol consumption from the present 18 to 21. A similar case for a UK advertising ban was made by the British Medical Association in 2009,9 although without result. Our Minister's stance is based on the reduction in smoking that followed the ban on tobacco advertising,10 one of the principal aims of the Tobacco Products Control Amendment Act of October 2000 having been to 'Reduce the pressure on young people to begin a lifelong (tobacco) addiction at age 15 and younger.'

In this issue of SAMJ, the public health case for the Minister's proposed ban is presented by Parry and colleagues,11 who cite evidence that advertising sets out to deliberately target young people, while the early age at which our youth begin drinking, and the harms that ensue, are amply captured in the analysis by Ramsoomar and Morojele.12

The Minister will hope to exploit the evidence6 that delaying a young person's first drink will prevent development of harmful drinking habits. The impact on SA's youth, so many of whom lead socially and economically deprived lives, may however prove disappointing.